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• SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION ephone: (209) 468-3449 Fax:(209)468-3433 Web:www.sigov.orq/ehd UNIT IV P#�'x �J��lv;tl��-i HFAI_T�t WELL PERMIT APPLICATION C,' ;€'i "`-e c RVI C, 'ANON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County)Env__irr�onmental Health Department. Assessor' 7� ti- '1�SI r SVib _ Cross Street Loh--------Zip a��J�_ Parcel#— J=�-XL_I1�- Well Location _thpf j� City _____ Property City- �A -------- Zip_ o -Phone# Owner ---------- Address 776 y �7 / 1J +1' ��II, I" ) , Cit SfP Lic# �V�d`�Phone----�--------- -A ---.--- - C-57 Contractor y�NL_U'_�1IL�7.�`S[��_'.Address 31 {y_�t�'_�L�1cL��'�f-(��-� Y_I,_,�� l� �7 �/� W _� JJf�1 Q Ic�2 lYn-J)1!`( eitY _FI 1i1?�^^Z- is#----�--Phone_-1kj l�'ewl t Consultant/SubCntr-_A'- Iti_ ___ Address__ W 3 ��1 A-A- 1---_-Townshipj- `�----------- Range-S�----- Section _ -- GIS Coordinates:X 1�-_+�Dl�______-- .Y --- f---- -------f-- WORK TO BE PERFORMED: DESTRUCTION(CHOOSE TYPE BELOW) J&NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) C,SOIL BORING#--.3A ---------------------------- ❑OVER-BORE DIAMETER---------------------- WELL# _to----------------------------------- ❑PRESSURE GROUT -------------------- ,� GROUT SPECIFICATIONS ____________________ ❑*OTHER ------------------------------------— ------------------------------------------—- TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC... [IMULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_____ ❑EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS----- TYPE OF CASING:❑STEEL KPVC ❑ OTHER ❑VAPOR ElMUD ROTARY_______________ DEPTH OF GROUT SEAL ____Y C 3-----TREMIE TYPE TO BE USED AUGERS❑HOSE ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)V-- GROUT SEAL PUMPED:❑Yes'XINo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') GROUT SPECIFICATIONS _ _h.�A -- - — OIL BORING [I HAND AUGER_ __________ �./� OTHER: _—_____—_-_- APPROX.BORING DEPTH _____✓ --_-__-____ ❑BOLTED TRAFFIC BOX OR jL STOVE PIPE ❑OTHER: —-------------- ❑ ONDUCTOR g`SING PROP,O^SE,D,y_�__�_�__p _ (if YES,list specrfications in comment section) COMMENTS:. v �--v---?,tom[0 ------ NOTE: _ -- _ Q/h� L-�� `n",.�_----------------------------------------- NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulatio s,and II appliicab a California Laws. `A '`1tlo,��_�/ i-1 �`g:l1------ ------------------------------ Title/Company � f-(� _µiJ' JU Signed - f/V q ( {�� ,^�,,� ------------Date_fi oho-!------------------- Print Name ,�, �-y='�1�=�� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: _�Z I ------------ -------- �_!✓_`-- tom !mac[• -�D ,-_---C.O-L. - qp ---------------- PLAN DATED:----0 CL L -- - - -- ---------------------------- DATE - - ------ /6!3 D AREA--L--L- WORK Q�7--- APPLICATION ACCEPTED BY _ _ ________ ------------ -- DATE ISSUED -- ( - --- 1 / --------------------------- FINAL INSPECTION BY II I � t9�--- -------- DATE -------- GROUT INSPECTION BY 1_ ____- DESTRUCTION INSPECTION BY------------ ------------- ---- --- DATE-------------------------------------------------------- -------------- COMMENTS/CONDITIONS: .--- --� --- -------------- --------------- EfE AID# FAC# AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE 3 /J 3 D SR#Do�B?!D t�� 1 WAIVER C57 LETTER 0F AUTHORIZATION TO SIGN PER IT --------ENCROACHMENT DOC-------